Primary care at the forefront of colorectal cancer screening

Transcription

1 Primary care at the forefront of colorectal cancer screening Presentation by Bohumil Seifert Department of General Practice, 1st Faculy of Medicine, Charles University in Prague 04/05/2012

2 Introduction Prague Institute of General Practice, Prague Training practice 2 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

3 Special interest in colorectal cancer screning A member of a Foundation which initiated colorectal cancer screening in the Czech Republic in 2000 Representative of GPs in Czech National Colorectal Cancer Screening Committee Education for GPs and public on CRC screening Research on - the role of primary care physicians in screening - attitudes toward screening in target population - FOBT methods 3 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

4 Characteristics of the medicine in the 3rd millenium Key issue: Non-communicable diseases Fascinating technology development Succeses in diagnostics and treatment and improvement of prognosis of serious diseases Successes and expectations push medicine towards prevention towards pro-active inteventions in asymptomatic people 4 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

5 Prevention and screening Consequencies: Ethics (nature of patient doctor relation) Safety Costs Capacity 5 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

6 Colorectal cancer is the most preventable visceral form of cancer Stage of diagnosis matters! Early diagnostics helps to increase 5-year survival: Duke s A (90%) v. stage with distant metastases ( 10%) Colorectal cancer is preventable before exists. Identification and excision of risk polyps About half of polyps/cancers bleed and blood can be detected by simple test. Colonoscopy is a method with high diagnostic and curable capacity 6 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

7 Early diagnostics of colorectal cancer The principal method of identification of colorectal cancer stays symptomatic presentation to GPs who are source of referral to secondary care. 90% of colorectal cancers detected Importance of research on early diagnostics 7 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

8 Early diagnostics of colorectal cancer GP Competence Interdisciplinary cooperation Referral system Capacity Access to colonoscopy, waiting times Prioritization Research: -on sensitivity, specificity, PPV of symptoms -on markers (ifob, M2-PK, calprotectin stool test) 8 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

9 Role of primary care in prevention Primary prevention Secondary prevention: -screening programmes for high risk persons -screening programmes for average risk p. Early diagnosis in symptomatic Quality of care/tertiary prevention 9 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

10 CRC screening: Implications for General Practice The involvement of GPs varies in countries according to The involvement of GPs varies in countries according to chosen strategy: chosen strategy: Direct: performing FOBT (CR, SLO, GER) Direct: performing FOBT (CR, SLO, GER) Indirect: recruitment for colonoscopy screening (Pol) Indirect: recruitment for colonoscopy screening (Pol) Supportive: administrative, advices (UK) Supportive: administrative, advices (UK) The involvement of people Population The involvement based screening of people (central invitation UK) Organized screening (GP/patient activities,ge,czech) Opportunistic screening (Poland) Population based screening (central invitation UK) Organized screening (GP/patient activities,ge,czech) Opportunistic screening (Poland) Lionis C. Colorectal cancer screening and the challenging role of general practitioner/ family physician: an issue of quality, Quality in Primary Care 2007; 15: Seifert B., The role of primary care in colorectal cancer screening: The experience from the Czech Republic, Neoplasma, 2008; 55: Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

11 Benefits of primary care involvement in screening program complex approach to person personalised care additional value of preventive/screening programs (CV, GYN, MAM, CRC) cheaper 11 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

12 Burden of screening program in primary care Workload (up to 300 FOBT per year per practice) Organization issues Ethics Bad news 12 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

13 What matters the most in screening? If we put money in colorectal cancer screening what affects the most the outcomes? 1. Adherence rate? 2. Choice of primary test? 3. Quality/capacity of endoscopic services? 4. Program monitoring /data collection? 13 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

14 1. Adherence rate 14 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

15 Population based v. organized screening Programs using invitation system show higher adherence of target population Central invitiation is the only way how to get participation over 50%. Invitation via GP offices increases the adherence rate in 8% (UK) CZECH PROGRAM: letters administered by sick funds (different for all three programs) will invite people to GPs (gynaecologists, mamma centrum) since Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

16 1. Choice of primary test 16 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

17 European guidelines: FOBT Dietary restriction is not indicated for programmes using either guaiac-based or immunochemical tests Drug restriction is not recommended for population screening programmes using either guaiac-based or immunochemical test The ifobt is preferable over gfobt (higher participation, smaller number of stool samples needed, automated reading, greater sensitivity for detection of advanced adenomas, similar PPV)

18 Optimal FOBT Without diet restriction Simple (user friendly) quantitative sampling Easy logistics (POCT?) Automatic reading Cut off options with regards to - optimal sensitivity and specificity - safety, capacity and cost/benefit - risk groups (men, seniors, diabetics) Quantitative ifob tests 18 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

19 FOBT: Cut off optimalization CUT OFF high low Number of colonoscopies Sensitivity Specificity PPV Chen, 2007: Rossum, 2009: ng/ml faecal hemoglobin 75 ng/ml for the Netherland 200ng/ml where CS capacity is insuff. Recent Czech study shows, that suggested cut off 75ng/ml would mean FOBT positivity rate 12-16% compare to current 4% with gfobt. 19 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

20 4. Program monitoring/data collection? 20 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

21 Data collection Epidemiology: incidence prevalence mortality staging 5 years survival Quality of life Outcomes, Efficiency, Screening: FOBT PS colonoscopy S colonoscopy Follow up Diagnostics Treatment Costs, Capacity Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

22 Primary care data: Effect of measures for improvement centrally collected (hard) data/indicators: - FOBT adherence rate - FOBT positivity rate - GPs, gynaecologists involvement - regional differencies primary care collected data (experimentally) - waiting times for colonoscopies - compliance with colonoscopy in FOBT positives - feedback on endoscopic services/adherence to guidelines Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

23 Colorectal Cancer: Imperatives for primary care Do not miss a symptomatic cancer/refer in time! Identify high risk patients! Screen for colorectal cancer! 23 Primary care at the forefront of colorectal cancer screening. Presentation by Bohumil Seifert

24 Thank you for attending, if you are interested in finding out more about UEG visit Like us on Facebook at Tweet us Presentation by Bohumil Seifert Department of General Practice, 1st Faculy of Medicine, Charles University in Prague 17/05/2012